Get Va Form 216-a 2019

Filling out the VA Form 216-A is a critical step for individuals seeking an external review of their health insurance carrier's denial. This guide will provide a clear, step-by-step approach to help users complete the form easily and accurately, ensuring they have the necessary information to submit their request.

Follow the steps to successfully complete the VA Form 216-A online.

1. Click the ‘Get Form’ button to access the VA Form 216-A and open it for editing.
2. Begin by filling out the applicant's information. Indicate whether the applicant is a covered person, provider, or authorized representative by checking the appropriate box.
3. Provide the covered person's details, including their name, street address, city, state, zip code, date of birth, and phone number.
4. Enter the insurance information by providing the health carrier's name, the covered person's insurance ID number, the insurance claim/reference number, and the health carrier's mailing address and phone number.
5. Include employer information, noting the employer's name and phone number. Confirm whether the health coverage is a self-funded plan.
6. Fill in the treating health care provider's information, including their name, address, contact person, and phone number.
7. Select the reason for the health carrier's denial by checking the relevant box. Ensure you have reviewed the options clearly, as only certain reasons are eligible for external review.
8. Summarize the external review request by entering a brief description of the denied health care service or treatment. Remember to attach a copy of the denial letter from your health carrier; do not attach medical records at this stage.
9. If you want to request an expedited review, indicate whether the service has already been provided and check the necessary boxes regarding expedited requests.
10. Finally, sign and date the form to consent to the release of medical records. Ensure that you have provided accurate information throughout this process.
11. Once you've reviewed the completed form for accuracy, save your changes, and choose to download, print, or share the VA Form 216-A as needed.

Take the next step in your health care journey by completing the VA Form 216-A online today.